11.15 Hepatitis

The term hepatitis means inflammation of the liver. Hepatitis can be an acute or a chronic condition. When it lasts for six months or less, it is considered acute, and when it lasts over six months, it is considered chronic. The severity of hepatitis can range from mild to severe based on the source of the inflammation.^[1]

Pathophysiology

Hepatitis is commonly caused by the viruses of hepatitis A, B, C, D, and E. Hepatitis A, B, and C are the most common viral causes. Hepatitis A is commonly transmitted via the fecal to oral route and is common in places where there is poor sanitation. Hepatitis B and C are transmitted via contact with infected body fluids via contaminated blood transfusions, sharing of needles, or other parenteral measures. Hepatitis B and C can also be transmitted sexually and via pregnancy/childbirth. The incubation period for viral hepatitis ranges from four to twelve weeks, depending on the specific virus. Hepatitis A is usually an acute condition, but hepatitis B and C can become chronic illnesses and can lead to liver cancer or other complications.^[2]

Hepatitis D is inflammation of the liver that requires the presence of hepatitis B virus for viral replication. Hepatitis D infection cannot occur in the absence of hepatitis B virus, but it occurs concurrently or after being infected with Hepatitis B virus. Hepatitis E is transmitted mainly through contaminated drinking water and is common in low- and middle-income countries with limited access to essential water, sanitation, hygiene, and health services. The infection is usually self-limiting and resolves within two to six weeks. Occasionally, serious complications such as acute liver failure develops, which can be fatal.^[3]

Hepatitis is also linked to a variety of autoimmune disorders. Autoimmune hepatitis is when the body develops antibodies that attack the liver that are triggered by exposure to certain drugs or viruses.^[4]

Hepatitis can also be caused by the misuse of alcohol or drugs that can lead to death of liver cells, but the exact mechanism of action is unclear.^[5]

Assessment

Regardless of the causes of hepatitis, the signs and symptoms are similar. Common early signs and symptoms of hepatitis are loss of appetite, nausea, vomiting, and fatigue. It can also be asymptomatic. As the disorder progresses, jaundice, pain in the right upper quadrant, an enlarged liver, light-colored stools, and dark-colored urine may occur. In severe cases of autoimmune and alcoholic hepatitis, clients may also have excessive fluid buildup in the abdomen referred to as ascites and mental status changes related to the buildup of toxins, such as ammonia, referred to as hepatic encephalopathy.^[6]

Common Laboratory and Diagnostic Tests

Lab values that may be altered in hepatitis are liver enzymes, bilirubin, coagulation labs, and ammonia levels. Coagulation labs such as prothrombin time (PT) and internalized normalized ratio (INR) may be increased due to the liver’s role in blood clotting, resulting in increased risk for bleeding. Ammonia levels may be elevated in severe cases, causing hepatic encephalopathy.^[7] To diagnose viral hepatitis, blood tests can detect the presence of antibodies to viruses. There are a variety of blood tests used to diagnose autoimmune hepatitis, but the gold standard is a liver biopsy.

Liver biopsies may be performed to establish a diagnosis of hepatitis and assess the extent of the disease.^[8]

Nursing Diagnosis

Nursing diagnoses for clients with hepatitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Nursing priorities for clients with hepatitis include managing fatigue, promoting adequate nutrition, reducing the risk for bleeding, and providing health teaching. Common nursing diagnoses for clients with hepatitis are as follows^[9]:

• Fatigue
• Imbalanced Nutrition: Less Than Body Requirements
• Risk for Bleeding
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes for clients with hepatitis include the following^[10]:

• The client will maintain adequate fluid volume during hospitalization, as evidenced by stable vital signs, good skin turgor, capillary refill less than two seconds, strong peripheral pulses, and appropriate urinary output.
• The client will report an improved sense of energy and participate in desired activities within two weeks of treatment.
• After the teaching session, the client will verbalize understanding of the disease process, prognosis, and potential complications.
• After the teaching session, the client will verbalize understanding of the treatment regiment and initiate necessary lifestyle changes. 

Interventions

Medical Interventions

Medical treatment for acute viral hepatitis consists of supportive care such as rest, fluids, and a nutritious diet.^[11] Chronic hepatitis may be treated with antiviral medications and medications that suppress the immune system, but these medications can have serious side effects that must be monitored.^[12] Additionally, medications that adversely affect the liver are avoided, such as acetaminophen and paracetamol.^[13]

Autoimmune hepatitis is typically managed with steroids or other medications that suppress the immune system. Liver transplantation may be performed for clients with severe hepatitis resulting in liver failure.^[14]

Clients with alcoholic hepatitis should be referred to treatment for substance use disorders and abstain from the use of alcohol. Short-term steroid administration may be prescribed to reduce inflammation. In severe cases of liver failure, liver transplantation may be performed for clients who have abstained from alcohol or other drugs for six months or more.^[15]

Vaccines are available to prevent the transmission of viral hepatitis A and B. Hepatitis A vaccines should be offered to those traveling to endemic areas or at high risk for contracting the disorder. Hepatitis B vaccine is included on the newborn vaccination schedule and should also be taken by those who did not receive the vaccine as an infant and are at risk for blood exposure, such as health care workers.^[16]

Nursing Interventions

Nursing priorities for clients with hepatitis include managing symptoms, providing supportive care, preventing further liver damage, monitoring liver function and disease progression, and administering antiviral medications as prescribed. Nurses also teach clients about lifestyle modifications to promote liver health, the prevention of hepatitis transmission to others, and to promptly report symptoms of potential complications to the health care provider.^[17]

Nursing Assessments

Nurses monitor vital signs, 24-hour input and output, daily weight trends, and for signs of edema. They monitor for ascites by measuring abdominal girth. They assess peripheral pulses, capillary refill, skin turgor, and mucous membranes, as well as for signs of bleeding such as hematuria, melena, ecchymosis, and oozing from gums and IV sites. They monitor laboratory values such as serial liver enzymes, hemoglobin, hematocrit, albumin, and clotting times.^[18]

Nursing Actions

Nursing interventions include the following actions^[19]:

• Optimize nutrition: Anorexia is a common symptom. A dietician is consulted to plan a diet according to the client’s current nutritional needs. Medications are administered related to nutritional intake as prescribed such as antiemetics, antiulcer medications, vitamin B complex, vitamin C, and other nutritional supplements. Oral care is encouraged before meals to promote appetite.
• Promote fluid balance: Prescribed intravenous fluids and electrolytes are administered as indicated. Fluid restrictions are implemented if prescribed for fluid overload.
• Prevent bleeding: The client is encouraged to use an electric shaver and a soft-bristled toothbrush or sponge swabs and mouthwash to prevent bleeding. Additional bleeding precautions are described in the "Thrombocytopenia" section of the "Hematological Alterations" chapter.
• Manage fatigue: Bed rest is typically prescribed during acute illness. Nurses implement a quiet environment and limit visitors as needed. Nurses teach about energy-conserving techniques such as sitting when showering and scheduling rest periods. Additional energy management interventions are described in the "Iron Deficiency Anemia" section of the "Hematological Alterations" chapter.
• Prevent skin breakdown and maintain skin integrity: Skin is routinely assessed for areas of redness and breakdown. Clients are encouraged and assisted to change position frequently. To manage the common symptom of itching, clients are encouraged to take cool showers or use baking soda baths. Alkaline soaps should be avoided. Diversional activities can be implemented to manage the discomfort of itching, and the use of knuckles instead of fingernails can be suggested if the desire to scratch is uncontrollable. Fingernails should be cut short, and gloves should be applied while sleeping to prevent skin damage from itching.
• Provide emotional support: Nurses perform active listening and encourage the client to verbalize their feelings and concerns. Nurses avoid making judgmental statements about lifestyle choices in cases of hepatitis due to substance misuse and instead focus on abstinence and efforts toward recovery. They teach about stress management techniques and positive coping strategies such as progressive relaxation, visualization, and guided imagery. Prescribed sedative medications are administered for anxiety as indicated, such as diazepam and lorazepam.
• Make referrals: Nurses refer clients to community resources, support groups, and drug/alcohol treatment programs as indicated.

Client Teaching

Nurses provide health teaching about several topics to clients with hepatitis^[20]:

• The client's understanding of the disease process, prognosis, and treatment regimen is assessed, and additional information is provided as indicated.
• Information about preventing the transmission of hepatitis is provided. Close contacts may require administration of gamma-globulin to prevent disease. When liver enzymes are elevated, strict handwashing should be performed by the client and their household members, personal items should not be shared, and intimate contact such as kissing and sex should be avoided. Clothes, dishes, and toilet facilities should be sanitized.
• Resumption of activity as tolerated is planned, along with adequate periods of rest. Prescribed restrictions on heavy lifting, strenuous exercise, and contact sport are reinforced.
• Consumption of a healthy, balanced diet is encouraged to promote healing and tissue regeneration. Managing bowel function with adequate intake of fluids and fiber, and moderate activity is encouraged.
• Side effects of over-the-counter and prescribed medications that affect the liver, such as acetaminophen, aspirin, sulfonamides, and some anesthetics, are discussed. Notification of future health care providers about the diagnosis of hepatitis is strongly encouraged, especially if medications are prescribed, because some medications are toxic to the liver and others can cause cumulative toxic effects and chronic hepatitis.
• The importance of follow-up appointments and laboratory evaluation is emphasized, along with abstaining from alcohol and other drugs affecting the liver for a minimum of 6 to 12 months or longer.

Evaluation

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.